These changes being proposed to Virginia's Medicaid Waiver Program may be presented as administrative or operational changes, but they actually affect how people with intellectual and developmental disabilities (ID/DD) receive the assistance they need to live safely in their homes and communities, how families manage increasingly complex and demanding caregiving and administrative responsibilities, and whether individuals are able to keep meaningful choice and control over their lives. 

Taken as a whole, there are 3 especially significant changes, alongside 5 other proposed waiver amendments.  The removal of the EVV exemption for Live-in Caregivers must be an added consideration in these proposed Medicaid Waiver changes since all of this is occuring at the same time.

1. A 56-hour weekly limit on personal assistance is an arbitrary threshold which does not ensure the care needed for health, safety, and ability to live in the community.

1. It is not person centered to dictate that ID/DD supports will be limited to 8 hours a day.  

2. The “exception” process will in all probability be managed by AI which will as we have seen with medical appeals, reject all appeals.  Only one appeal will be allowed, then afterwards a new Authorization will be issued.  This means that attendants will be unpaid and there will be no ability to claim retroactive payment for hours lost during the first authorization denial and appeal process.

3. This only serves to add barriers and delays which will save the state money, but which will mean recipients will lose caregivers and potentially their ability to live in the community.  

4. This 56-hour cap on care can become a reduction in care if exceptions are difficult to obtain, delayed, or denied.

5. Virginia adopted the SIS-A2 to better assess the intensity of support needs, including complex behavioral challenges. Yet the proposed 56-hour personal assistance limit risks disconnecting those documented needs from the services actually authorized. Under 12VAC30-122-460, personal assistance expressly encompasses behavioral and cognitive impairments, including safety supports. DMAS must ensure that SIS-identified needs translate into individualized service authorizations, with meaningful exceptions where necessary, rather than allowing an arbitrary hourly threshold to override documented disability-related needs.

6. Will current services will continue during the exception process like a “stay put” provision until the final determination is made?  

Summary:  Without exceptions that are timely, transparent, and based on individual need, on the face of it, this cap is simply a cost containment measure. An exception process that is difficult to navigate can turn this “soft cap” into an administratively applied hard cap.  The SIS process which documents actual support need is disconnected from the services which will be provided. All this places burdens on individuals that in all practicality mean they will lose the ability to live in the community and will be institutionalized.  

2. Replacing services facilitation with support brokerage means a change from a personalized, choice model to primarily administrative or transactional model.

   1. A broker model changes how individuals receive help with consumer-directed (CD) services and administrative requirements placed on individuals by the Medicaid Waiver process. 
   2. DMAS has not provided any insight into the final division of responsibilities, broker qualifications, caseloads, and whether there will be any independent oversight. Will this model improve the quality of service to or reduce administrative burdens on individuals?
   3. Combining payroll administration and support functions raises questions about conflicts of interest and who will independently review disputes.

Summary:  The absence of any real effort to improve a service before it is removed and replaced with an administrative process, illustrates the real interest DMAS is serving.  DMAS is certainly no longer interested in supporting recipient choice but rather they are ensuring services will be less accessible to individuals and families will be expected to manage increasingly demanding administrative requirements without adequate assistance.

3. The removal of higher-level of care reviews for CCC+ services shows that DMAS is now serving the interests of DMAS itself rather than the well-being of the Medicaid recipient. 

   1. Annual Level of Care review (LOC) is a • federal mandate- 42 §441.302 (c) (2) “The goal of the review is to determine if the member continues to need the level of care provided and would, but for the provision of waiver services, otherwise be institutionalized.”
   2. To qualify and be authorized for Medicaid reimbursement of Long-Term Care Services, the individual must also be “at risk” for Nursing Facility, hospital or intermediate care placement within 30 days in the absence of the Waiver services.  
   3. The goal of a Care Review is to determine if the individual continues to need the level of care provided and would, but for the provision of waiver services, otherwise be institutionalized
   4. It seems that DMAS has already been implementing this proposed change of removing the higher-level of care reviews since families are reporting a reduction in care hours. These notifications are coming in form letters sent to them without any notice or an appeal process.  
   5. These reviews provide a critical clinical safeguard against erroneous termination of medically necessary waiver services, particularly where eligibility depends on complex medical and functional assessments.
   6. Pushing families to a Fair Hearing process is not a substitute for meaningful clinical oversight before termination. 
   7. Has DMAS completely capitulated and is now serving the interests of itself rather than the interests of the Medicaid recipient? 
   8. The logical end result is people with complex medical and behavioral needs will be forced into institutional care settings and will not be authorized the care they require to return to the community.  

Summary: Removing mandatory independent nursing oversight risks erroneous eligibility determinations, particularly for individuals with complex medical and functional needs. Such errors can result in wrongful termination of essential services, increased institutionalization risk, and substantial burdens on families forced to pursue administrative appeals. DMAS should retain this critical clinical safeguard for both Fee-for-Service (FFS) and Managed Care Organizations (MCO) providers.

Additional Comments of Note:

The application of Electronic Visit Verification (EVV) to live-in caregivers should be delayed.

While Electronic Visit Verification (EVV) is not the subject of this CMS plan amendment application by DMAS, we want to reiterate our serious concerns about eliminating the live-in caregiver exemption which is still allowed by federal law.

• DMAS continues to threaten the Medicaid recipient with severe consequences for normal human mistakes made by the live-in caregiver.  If accuracy and system integrity are the goal, then why is someone being punished for correcting human mistakes made using an imperfect digital device which constantly has errors?
• DMAS threatens that the client will lose eligibility if an attendant makes shift adjustments in the CareAttend app that are considered non-compliant.
• Quote from an email May 15, 2026
• “Thank you for contacting CDVA. After reviewing the account, it appears XXXX made shift adjustments for date of service 4/XX/26. 

Please ensure that attendants do not make any shift corrections using the Web Portal. Additionally, if an attendant makes shift adjustments in CareAttend for dates other than the current day, it will also be considered non-compliant. All adjustments on CareAttend must be completed in real time.

Please be mindful, multiple non-compliance time entries can result to the client's losing eligibility. If you have additional questions, please call 888-444-8182. 

• Families are reporting continued struggles with clocking in on CareAttend when there is a seizure, behavior management issue or complex medical care demand. 
• DMAS has not allowed families to provide input on any of these rules regarding EVV and live-in caregivers and has completely ignored the concerns expressed in the Townhall March, 2020 public comments.  https://townhall.virginia.gov/L/Comments.cfm?StageID=8364 

Summary: DMAS must delay application and use of EVV for live-in caregivers until DMAS consults directly with affected families, provides clear and practical implementation guidance, and establishes explicit protections against adverse consequences that result from ordinary human error or technical problems with the CareAttend application.

We also align ourselves with the posted comments by Lucy Beadnell, The Arc of Northern Virginia and Moms In Motion and the disAbility Law Center of Virginia

Respectfully submitted,

Virginia Autism Project